Get the free Surplus lines disclaimer statement - Strickland General Agency

SURPLUS LINES DISCLAIMER STATEMENT The undersigned insured hereby acknowledges: A. I understand the insurance coverage provided by this policy is written by a non licensed insurer for the State of

How to fill out surplus lines disclaimer statement

How to fill out surplus lines disclaimer statement:

1. Begin by including the name of the insurer and the policy number.
2. Clearly state that the policy being issued is a surplus lines policy.
3. Include the full name and address of the insured party.
4. Specify the effective date and the expiration date of the policy.
5. Clearly state any exclusions or limitations of coverage.
6. Include a statement that the policy is not covered by the state guaranty association.
7. Provide contact information for the surplus lines broker or agent.
8. Sign and date the surplus lines disclaimer statement.

Who needs surplus lines disclaimer statement?

1. Insurance companies or brokers that are issuing surplus lines policies.
2. Policyholders who are purchasing insurance coverage from a surplus lines market.
3. State insurance regulators who require surplus lines disclaimer statements to be filed.

For pdfFiller’s FAQs

What is surplus lines disclaimer statement?

Surplus lines disclaimer statement is a statement that discloses to policyholders that the insurance policy they are purchasing is not covered by state guaranty funds.

Who is required to file surplus lines disclaimer statement?

Insurance agents and brokers are required to file surplus lines disclaimer statements when selling surplus lines insurance policies.

How to fill out surplus lines disclaimer statement?

Surplus lines disclaimer statements can typically be filled out electronically through the state's insurance department website or manually by filling out a specific form provided by the department.

What is the purpose of surplus lines disclaimer statement?

The purpose of surplus lines disclaimer statement is to inform policyholders that the insurance policy they are purchasing is not protected by state guaranty funds in case of an insurer insolvency.

What information must be reported on surplus lines disclaimer statement?

Surplus lines disclaimer statements must include the name of the insured, policy number, effective date, expiration date, coverages provided, and a statement indicating the policy is not covered by state guaranty funds.

How do I edit surplus lines disclaimer statement online?

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